Healthcare Provider Details

I. General information

NPI: 1366735466
Provider Name (Legal Business Name): RENDEZVOUS MEDICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2011
Last Update Date: 10/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1035 ROSE LN SUITE B
RIVERTON WY
82501-2286
US

IV. Provider business mailing address

1035 ROSE LN SUITE B
RIVERTON WY
82501-2286
US

V. Phone/Fax

Practice location:
  • Phone: 307-856-0382
  • Fax: 307-856-0385
Mailing address:
  • Phone: 307-856-0382
  • Fax: 307-856-0385

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JOHN W MERCER
Title or Position: PHYSICIAN OWNER
Credential: MD
Phone: 307-856-0382